Provider Demographics
NPI:1841405396
Name:EDNA RICHARD M D
Entity Type:Organization
Organization Name:EDNA RICHARD M D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-567-6691
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-789-2550
Mailing Address - Fax:
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:B390
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2333
Practice Address - Country:US
Practice Address - Phone:312-567-6691
Practice Address - Fax:312-328-7895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2160083333OtherBCBS PROVIDER ID